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Treatment Algorithms for the Management of Lung Cancer in NSW Guide for Clinicians Background The Cancer Institute New South Wales Oncology Group – Lung (NSWOG Lung) identified the need for the development of treatment algorithms for the management of lung cancer in NSW. This need was based on evidence that lung patients were often not offered treatment due to the belief that there were limited treatment options available. The Cancer Epidemiology Research Unit of the Cancer Council NSW was commissioned to develop the treatment algorithms. The treatment algorithms were developed for both non small cell lung cancer and small cell lung cancer and are based on the NICE guidelines, with input from a range of NSW based lung cancer clinicians. Modified versions of the treatment algorithms for consumers and general practitioners have been placed on the Cancer Institute NSW eviQ website (www.eviQ.org.au). Contents 1. Management recommendations for Non Small Cell Lung Cancer • Stage I • Stage II • Stage IIIA • Stage IIIB • Stage IV 2. Flowcharts for Non Small Cell Lung Cancer • Stage I • Stage II • Stage IIIA • Stage IIIB • Stage IV 3. Management recommendations for Small Cell Lung Cancer • Limited • Extensive 4. Flowcharts for Small Cell Lung Cancer • Limited • Extensive 1. Management Recommendations for Non-Small Cell Lung Cancer by Stage Clinical Stage (TNM 7th Ed.) Management Supportive Care For details of chemotherapy and radiotherapy protocols, refer to eviQ (www.eviq.org.au) Pre-Treatment Assessment: I-IV 1. Confirm stage 2. Assess patient’s fitness for treatment (MDT assessment: Surgeon and Respiratory Physician to assess fitness for surgery, Medical Oncologist for chemotherapy and Radiation Oncologist for radiotherapy) 3. Stabilise other conditions first • I (T1N0, T2N0) 1. Surgery (ECOG 0-2) lung cancer nurse 2. Definitive RT (ECOG 0-2) • Access to psychosocial and spiritual support • Look for support in community setting • GPs to play important role throughout (monitor 3. Palliative RT (ECOG 3-4, symptomatic) 4. Supportive care with symptom monitoring (ECOG 3-4, asymptomatic) Access to clinical cancer care coordination or for onset of symptoms) II (T1a,bN1, T2aN1, T3N0) 1. Surgery + adjuvant chemotherapy if N1. Consider chemotherapy if N0# (ECOG 0-2) 2. Definitive ChemoRT – concurrent or sequential (ECOG 0-2) # IIIA (T1-3N2, T3N1, T4N0-1) • Access to clinical cancer care coordination or lung cancer nurse 3. Definitive RT alone (ECOG 0-2) • Access to psychosocial and spiritual support 4. Palliative RT (ECOG 3-4, symptomatic) • Look for support in community setting 5. Supportive care with symptom monitoring (ECOG 3-4, asymptomatic) • GPs to play important role throughout (monitor limited evidence for T3N0 MDT assessment prior to any treatment decisions for onset of symptoms) • lung cancer nurse Treatment based on investigative findings: CT suspicious, PET +ve, non bulky nodes, single station N2 1. Induction chemo then surgery +/- RT (ECOG 0-2) • Access to psychosocial and spiritual support • Look for support in community setting • GPs to play important role throughout (monitor 2. Surgery plus adjuvant chemo +/- RT (ECOG 0-2) 3. Definitive ChemoRT –concurrent or sequential (ECOG 0-2) 4. Definitive RT (ECOG 0-2, unfit for chemotherapy) 5. Palliative RT (ECOG 3-4, symptomatic) 6. Supportive care with symptom monitoring (ECOG 3-4, asymptomatic) Access to clinical cancer care coordination or for onset of symptoms) • Early involvement of palliative care services IIIA (T1-3N2, T3N1, T4N0-1) Continued CT suspicious, PET+ve, bulky nodes or multiple nodal levels 1. Definitive ChemoRT-concurrent or sequential (ECOG 0-2) 2. Definitive RT (ECOG 0-2, unfit for chemotherapy) 3. Consider Palliative RT if definitive RT contraindicated (ECOG 0-2, chest symptoms) 4. Palliative Chemotherapy if RT contraindicated (ECOG 0-2), no chest symptoms) 5. Palliative RT (ECOG 3-4, symptomatic) 6. Supportive care with symptom monitoring (ECOG 3-4, asymptomatic) Pathological Stage IIIA (Positive nodes found at surgery) • consider adjuvant chemotherapy and adjuvant RT 1. Definitive ChemoRT -concurrent or sequential (ECOG 0-2) IIIB (T1-3N3, T4N2-3) • 2. Definitive RT (ECOG 0-2, unfit for chemotherapy) Access to clinical cancer care coordination or lung cancer nurse 3. Consider Palliative RT if definitive RT contraindicated (ECOG 0-2, chest symptoms) • Access to psychosocial and spiritual support 4. Palliative Chemotherapy if RT contraindicated (ECOG 0-2), no chest symptoms) • Look for support in community setting 5. Palliative RT (ECOG 3-4, symptomatic) • GPs to play important role throughout (monitor 6. Supportive care with symptom monitoring (ECOG 3-4, asymptomatic) for onset of symptoms) • Early involvement of palliative care services IV (M1) Active treatment should begin with appropriate supportive care Treatment based on symptoms (local or systemic) Local Symptoms: • Palliative RT • Laser therapy (airway obstruction) • Stent (airway obstruction) • Drainage of pleural effusion +/- pleurodesis • Access to clinical cancer care coordination or lung cancer nurse • Access to psychosocial and spiritual support • Look for support in community setting • GPs to play important role throughout (monitor for onset of symptoms) Systemic Symptoms: Brain metastases • Surgery or stereotactic RT plus whole brain RT (solitary brain mets, ECOG 0-2) • Whole brain RT (multiple brain mets, ECOG 0-2) • Supportive care (ECOG 3-4) Bone metastases • RT for pain • Fixation to prevent fracture • Supportive care (ECOG 3-4) Other metastases • Chemotherapy +/- biologic agents • Supportive care (ECOG 3-4) • Early involvement of palliative care services 2. Flowcharts for the Management of Non-Small Cell Lung Cancer NSCLC Clinical Stage I (TIN0, T2N0) # + Confirm Stage I Patient fit for surgery? Yes *Surgery No What is patient’s ECOG score? ECOG 0-2 ECOG 3-4 ^Definitive Radiotherapy Is patient symptomatic? Yes ^Palliative Radiotherapy No # Supportive care with symptom monitoring • Smoking cessation will improve survival and quality of life + MDT assessment: the Surgeon plus Respiratory Physician together are best to assess fitness for surgery, the Radiation Oncologist for radiation and Medical Oncologist for chemotherapy # Consider supportive care (including): Access to clinical cancer care coordination or lung cancer nurse; Access to psychosocial and spiritual support; Look for support in community setting; GPs need to play important role throughout * Stabilise other conditions before active treatment ^ Follow radiotherapy protocols described in EviQ https://www.eviq.org.au/ NSCLC Clinical Stage II (T1a,bN1, T2aN1, T3N0) # + Confirm Stage II Patient fit for surgery? Yes No What is patient’s ECOG score? *^Surgery plus adjuvant chemotherapy if N1. Consider chemotherapy if T3N0~ ECOG 0-2 Patient fit for chemotherapy? Yes ^Defintive ChemoRT (concurrent or sequential) No ^Definitive Radiotherapy ECOG 3-4 Is patient symptomatic? Yes ^Palliative Radiotherapy No Supportive care with symptom monitoring • Smoking cessation will improve survival and quality of life + MDT assessment: the Surgeon plus Respiratory Physician together are best to assess fitness for surgery, the Radiation Oncologist for radiation and Medical Oncologist for chemotherapy # Consider supportive care (including): Access to clinical cancer care coordination or lung cancer nurse; Access to psychosocial and spiritual support; Look for support in community setting; GPs need to play important role throughout NSCLC Clinical Stage IIIA (T1-3N2, T3N1, T4N0-1) * Stabilise other conditions before active treatment ^ Follow chemotherapy and radiotherapy protocols described in EviQ https://www.eviq.org.au/ ~ Limited evidence for T3N0 NSCLC Clinical Stage IIIA (T1 -3N2, T3N1, T4N0-1) # + Confirm Stage IIIA Pathological Stage IIIA (Positive nodes found at surgery) *MDT assessment prior to any treatment decisions ^Consider adjuvant chemo and adjuvant RT What is patient’s ECOG score? ECOG 0-2 ECOG 3-4 Is patient symptomatic? CT and PET review. Consider biopsy if equivocal (EBUS or mediastinoscopy) Yes Non bulky nodes and single station N2 Bulky nodes +/multiple nodal levels *^Induction chemo then surgery +/- RT Or Surgery plus adjuvant chemo +/- RT Supportive care with symptom monitoring Would definitive RT be contraindicated by tumour size, respiratory function or comorbidity? Patient fit for surgery? Yes ^Palliative RT No No No Yes Patient fit for chemotherapy? Yes ^Definitive ChemoRT (concurrent or sequential) No ^Definitive Radiotherapy Patient has chest symptoms? Yes ^Consider palliative RT No ^Consider palliative chemo NSCLC Clinical Stage IIIB (T1-3N3, T4N2-3) +# * Confirm Stage IIIB What is patient’s ECOG score? ECOG 0-2 ECOG 3-4 Would definitive RT be contraindicated by tumour size, respiratory function or comorbidity? Yes Patient has chest symptoms? Yes ^Consider palliative RT No ^Consider palliative chemo Is patient symptomatic? No Yes Patient fit for chemotherapy? Yes ^Definitive ChemoRT (concurrent or sequential) ^Palliative Radiotherapy No Supportive care with symptom monitoring No ^Definitive Radiotherapy • Smoking cessation will improve survival and quality of life + MDT assessment: the Surgeon plus Respiratory Physician together are best to assess fitness for surgery, the Radiation Oncologist for radiation and Medical Oncologist for chemotherapy # Consider supportive care (including): Access to clinical cancer care coordination or lung cancer nurse; Access to psychosocial and spiritual support; Look for support in community setting; GPs need to play important role throughout * Stabilise other conditions before active treatment ^ Follow chemotherapy and radiotherapy protocols described in EviQ https://www.eviq.org.au/ NSCLC Clinical Stage IV (M1) +# Confirm Stage IV *Active treatment should begin with appropriate supportive care Symptom type Local Systemic What is patient’s ECOG score? ^Palliative RT Laser Therapy, Stent, Drainage of pleural effusion +/- Pleurodesis ECOG 0-2 Metastatic site Brain Number of brain metastases Solitary Surgery or Stereotactic RT plus whole brain RT Bone Radiotherapy (pain) Fixation (prevent fracture) ECOG 3-4 Supportive care Other ^Chemotherapy +/- biologic agents Multiple Whole brain RT • Smoking cessation will improve survival and quality of life + MDT assessment: the Surgeon plus Respiratory Physician together are best to assess fitness for surgery, the Radiation Oncologist for radiation and Medical Oncologist for chemotherapy # Consider supportive care (including): Access to clinical cancer care coordination or lung cancer nurse; Access to psychosocial and spiritual support; Look for support in community setting; GPs need to play important role throughout * Stabilise other conditions before active treatment ^ Follow chemotherapy and radiotherapy protocols described in EviQ https://www.eviq.org.au/ 3. Management of Small Cell Lung Cancer by Stage VA Staging Supportive Care Management For details of chemotherapy and radiotherapy protocols, refer to eviQ (www.eviq.org.au) • Limited 1. Chemotherapy concurrent chest radiotherapy (ideally RT should start with cycle 1 or lung cancer nurse 2 depending on local logistics and prophylactic cranial irradiation for complete or • Access to psychosocial and spiritual support • Look for support in community setting • GPs to play important role throughout • Access to clinical cancer care coordination or partial responders) 2. Palliative chemotherapy +/-radiotherapy (ECOG 3) 3. Supportive care (ECOG 4) Extensive 1. Palliative chemotherapy +/- radiotherapy; and prophylactic cranial irradiation for Access to clinical cancer care coordination or complete or partial responders lung cancer nurse 2. Palliative chemotherapy +/-radiotherapy (ECOG 3) • Access to psychosocial and spiritual support 3. Supportive care (ECOG 4) • Look for support in community setting • GPs to play important role throughout 4. Flowcharts for the Management of Small Cell Lung Cancer SCLC Limited Stage (Confined to one hemithorax, includes: ipsilateral hilar lymph nodes, mediastinal lymph nodes and ipsilateral Supraclavicular Fossa, lymph nodes, ipsilateral pleural effusion, not cytologically positive) +#* Incidental SCLC finding at surgery ECOG 0-2 ^Adjuvant chemotherapy ^Chemotherapy concurrent chest RT What is patient’s ECOG score? ECOG 3 ^Consider palliative chemotherapy +/- RT ECOG 4 Supportive care (ideally RT should start with cycle 1 or 2 depending on local logistics) Complete or partial response ^Prophylactic Cranial Irradiation • Smoking cessation will improve survival and quality of life + MDT assessment: the Radiation Oncologist is best to assess fitness for radiotherapy and Medical Oncologist for chemotherapy # Consider supportive care (including): Access to clinical cancer care coordination or lung cancer nurse; Access to psychosocial and spiritual support; Look for support in community setting; GPs need to play important role throughout * Stabilise other conditions before active treatment ^ Follow chemotherapy and radiotherapy protocols described in EviQ https://www.eviq.org.au/ SCLC Extensive Stage (anything beyond limited stage) +#* ECOG 0-2 ^Palliative chemotherapy +/- radiotherapy What is patient’s ECOG score? ECOG 3 ^Consider palliative chemotherapy +/- RT ECOG 4 #Supportive care Complete or partial response ^Prophylactic Cranial Irradiation • Smoking cessation will improve survival and quality of life + MDT assessment: the Radiation Oncologist is best to assess fitness for radiotherapy and Medical Oncologist for chemotherapy # Consider supportive care (including): Access to clinical cancer care coordination or lung cancer nurse; Access to psychosocial and spiritual support; Look for support in community setting; GPs need to play important role throughout * Stabilise other conditions before active treatment ^ Follow chemotherapy and radiotherapy protocols described in EviQ https://www.eviq.org.au/